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Active Surveillance for Low-Risk Prostate Cancer Worldwide: The PRIAS Study

Bul, Meelan; Zhu, Xiaoye; Valdagni, Riccardo; Pickles, Tom; Kakehi, Yoshiyuki; Rannikko, Antti; Bjartell, Anders LU ; van der Schoot, Deric K.; Cornel, Erik B. and Conti, Giario N., et al. (2013) In European Urology 63(4). p.597-603
Abstract
Background: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa. Objective: To update our experience in the largest worldwide prospective AS cohort. Design, setting, and participants: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) <= 10 ng/ml, PSA density <0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score <= 6. PSA was measured every 3-6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason >6... (More)
Background: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa. Objective: To update our experience in the largest worldwide prospective AS cohort. Design, setting, and participants: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) <= 10 ng/ml, PSA density <0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score <= 6. PSA was measured every 3-6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason >6 at repeat biopsy. Recommendation for treatment was triggered in case of PSA doubling time <3 yr or reclassification. Outcome measurements and statistical analysis: Multivariate regression analysis was used to evaluate predictors for reclassification at repeat biopsy. Active therapy-free survival (ATFS) was assessed with a Kaplan-Meier analysis, and Cox regression was used to evaluate the association of clinical characteristics with active therapy over time. Results and limitations: In total, 2494 patients were included and followed for a median of 1.6 yr. One or more repeat biopsies were performed in 1480 men, of whom 415 men (28%) showed reclassification. Compliance with the first repeat biopsy was estimated to be 81%. During follow-up, 527 patients (21.1%) underwent active therapy. ATFS at 2 yr was 77.3%. The strongest predictors for reclassification and switching to deferred treatment were the number of positive cores (two cores compared with one core) and PSA density. The disease-specific survival rate was 100%. Follow-up was too short to draw definitive conclusions about the safety of AS. Conclusions: Our short-term data support AS as a feasible strategy to reduce overtreatment. Clinical characteristics and PSA kinetics during follow-up can be used for risk stratification. Strict monitoring is even more essential in men with high-risk features to enable timely recognition of potentially aggressive disease and offer curative intervention. Limitations of using surrogate end points and markers in AS should be recognized. (Less)
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@article{d35925f0-62a9-4e0a-afdc-6849528390bb,
  abstract     = {Background: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa. Objective: To update our experience in the largest worldwide prospective AS cohort. Design, setting, and participants: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) &lt;= 10 ng/ml, PSA density &lt;0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score &lt;= 6. PSA was measured every 3-6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason &gt;6 at repeat biopsy. Recommendation for treatment was triggered in case of PSA doubling time &lt;3 yr or reclassification. Outcome measurements and statistical analysis: Multivariate regression analysis was used to evaluate predictors for reclassification at repeat biopsy. Active therapy-free survival (ATFS) was assessed with a Kaplan-Meier analysis, and Cox regression was used to evaluate the association of clinical characteristics with active therapy over time. Results and limitations: In total, 2494 patients were included and followed for a median of 1.6 yr. One or more repeat biopsies were performed in 1480 men, of whom 415 men (28%) showed reclassification. Compliance with the first repeat biopsy was estimated to be 81%. During follow-up, 527 patients (21.1%) underwent active therapy. ATFS at 2 yr was 77.3%. The strongest predictors for reclassification and switching to deferred treatment were the number of positive cores (two cores compared with one core) and PSA density. The disease-specific survival rate was 100%. Follow-up was too short to draw definitive conclusions about the safety of AS. Conclusions: Our short-term data support AS as a feasible strategy to reduce overtreatment. Clinical characteristics and PSA kinetics during follow-up can be used for risk stratification. Strict monitoring is even more essential in men with high-risk features to enable timely recognition of potentially aggressive disease and offer curative intervention. Limitations of using surrogate end points and markers in AS should be recognized.},
  author       = {Bul, Meelan and Zhu, Xiaoye and Valdagni, Riccardo and Pickles, Tom and Kakehi, Yoshiyuki and Rannikko, Antti and Bjartell, Anders and van der Schoot, Deric K. and Cornel, Erik B. and Conti, Giario N. and Boeve, Egbert R. and Staerman, Frederic and Vis-Maters, Jenneke J. and Vergunst, Henk and Jaspars, Joris J. and Stroelin, Petra and van Muilekom, Erik and Schroder, Fritz H. and Bangma, Chris H. and Roobol, Monique J.},
  issn         = {1873-7560},
  keyword      = {Active surveillance,Prostatic neoplasms,Prognostic factors,Prostate-specific antigen,Reclassification},
  language     = {eng},
  number       = {4},
  pages        = {597--603},
  publisher    = {Elsevier},
  series       = {European Urology},
  title        = {Active Surveillance for Low-Risk Prostate Cancer Worldwide: The PRIAS Study},
  url          = {http://dx.doi.org/10.1016/j.eururo.2012.11.005},
  volume       = {63},
  year         = {2013},
}